Sports Medicine Board Review Beth Raleigh, DO Hunterdon Family Medicine at Phillips Barber February 23, 2019
Sports MedicineBoard Review
Beth Raleigh, DOHunterdon Family Medicine
at Phillips Barber
February 23, 2019
Head
• Head & face injuries most common• Concussion
– No same day RTP– 2nd impact syndrome in children– Normal conventional imaging– Needs evaluation & clearance by
primary care provider– Return to Learn
Head
• Concussion– Return to Learn – once athletes are
asymptomatic with life & brain work, can consider RTP exercise protocol
– RTP exercise protocol is a graded exertional protocol
– Final Clearance by primary care provider
Neck
• Spurling’s– Cervical Radiculopathy– Foraminal impingement maneuver
• Stingers/Burners– Stretch injury to brachial plexus– Usually upper trunk - C5-6– Unilateral– Resolves in a few minutes– Common in Football
Upper Extremity - Shoulder
• Anterior Dislocation– Xray image– Tx: prompt relocation
• Clavicle Fracture– Midclavicular, min displacement– Tx: Sling 2-6 wks
• Rotator Cuff impingement– Neer & Hawkins tests
Shoulder Dislocation
• Anterior ≥ 95%
– Traumatic injury in Abducted & ER
position usual MOI
– Bimodal incidence
• Young male athletes – high impact
• Older deconditioned women - fall
• Posterior – seizure/electrocution
Shoulder Dislocation
• Clinical appearance– Arm held in Ab/ER, loss of normal
Deltoid contour• Diagnosis with X-ray• Normal
– AP images = humeral head overlaps with glenoid – see convex lens shape
– Y scapular – ball centered in Y or slingshot
Shoulder X-rays APNormal Anterior Dislocation
Shoulder X-rays Y scapularNormal Anterior Dislocation
Clavicle Fractures
• Fall on Shoulder• Fall off Bike, MVA• Zones of fracture
– Group 1 = Middle 1/3 ~ 69%– Group 2 = Distal 1/3 ~ 28%– Group 3 = Prox 1/3 ~ 3%
Clavicle Fractures
Treatment• Group 1 = Middle 1/3
– If minimal or nondisplaced• Nonsurgical in sling until healed
– Clinical healing = NTTP, pain free motion– Radiographic = callus seen on XR
– If significant displacement, shortening, comminuted or patient preference
• Refer for orthopedic consultation
Shoulder SeparationAC joint injury
• Typically from fall onto or hit to top of shoulder - FB, wrestling, hockey, etc.
• Pain, swelling, deformity over AC joint • Cross over test positive• X-ray to confirm diagnosis of
separation and rule out fracture• Sling until x-ray results come in
Shoulder SeparationAC joint injury
• Type I – AC partially torn, XR = WNL– Tx: Conservative = sling
• Type II – AC completely torn, CC partially torn or intact, XR = Wide AC– Tx: Conservative = sling
• Type III – Both AC & CC torn, XR = wide AC & CC– Tx: Refer for opinion
Adhesive Capsulitis
• Chronic condition – Causes:
• Immobility• Inflammatory event – bursitis/tendonitis• Medical – DM, Thyroid Dz, RA, Parkinson’s
• Sx: Stiffness, night pain, loss of function in ADL’s
• PE: Significant loss of Glenohumeral both AROM & PROM
Adhesive Capsulitis• Treatment:
– Physical therapy, stretching– Steroid injection may allow for
progress to normal motion– Often many months of physical therapy– Recovery 6 mo. – 2yrs– If all else fails…
• Manipulation under anesthesia (MUA)• Surgery
Little Leaguer’s Shoulder
Proximal humeral epiphysitis
– Pitcher’s injury– Age 11-16– Dx: X-rays bilateral; will see widening– Tx: Rest, PT- scapular stabilizers,
core, kinetic chain, pitch counts, pitching coach
Shoulder Tests
• Special Tests– Hawkins – impingement – Neer’s –impingement – Empty Can – supraspinatus injury/pain– Obrien’s & Crank test – labral injury – Apprehension – shoulder dislocation– Speed’s & Yergason’s - biceps
Elbow - Peds
• Nursemaid’s Elbow– Most common children’s elbow injury– Subluxation of Radial head– Toddler age– Hand held & yank/pull– Holds arm bent & close to side– Tx: Hyperpronation method
Elbow - Peds
• Little Leaguers Elbow– Medial Epicondyle Apophysitis
– MC young pitcher’s injury
– Age 9-14
– Progressive pain with throwing
– No trauma/injury history
– TTP medial elbow
– Tx: Rest 4-6 wks, Pitching coach to correct mechanics
Lateral Epicondylitis
• aka Tennis elbow– Pain/Inflammation of wrist extensor
origin at lateral epicondyle– Pain w/ resisted wrist & 3rd finger
extension– Can become chronic– Tx: Stretch, strength, PT, Ice, NSAID’s,
braces– Tx: CS injection = ST relief, no LT
benefit
Olecranon BursitisMost common superficial bursitis
• Acute bursitis – may benefit from aspiration & CS injection for diagnosis & symptom relief
• Septic suspected – Aspiration for diagnosis – send for fluid analysis
• Chronic from microtrauma – not likely to benefit from aspiration/injection
• Risk of iatrogenic septic bursitis
Khoadee, M. Common Superficial Bursitis. AFP 2017:95(4)224-231
Carpal Tunnel Syndrome– Median nerve irritation/compression at
transverse carpal ligament– Sx: pain & paresthesia into thumb & 1st 3
fingers, radial side 4th tip– Long term can cause thenar atrophy &
permanent nerve damage– PE: + Phalen’s, + Tinel’s– Diagnostics: Electrodiagnostic
Carpal Tunnel Syndrome• Treatment
– Mild = intermittent paresthesia/symptoms• CT night splint• Steroid injection• Oral steroids effective, but SE risk
– Moderate – severe ® refer• May need surgical decompression
Kothari, M. Carpal Tunnel Syndrome. Post, TW,ed.In: UpToDate. Waltham, MA: UpToDate Inc. (Accessed on February 8, 2019)
Upper Extremity - Wrist
• Dequervain’s syndrome– Stenosing tenosynovitis of APL
(abductor pollicis longus) & EPB (extensor pollicis brevis)
– + Finklesteins test– Tx: thumb spica splint,
corticosteroid injection
Upper Extremity - Wrist
• Scaphoid Fracture – After FOOSH injury– Snuffbox TTP– Initial XR often negative– Proximal 1/3 fractures = high risk of
nonunion or AVN– Thumb spica cast (non-displaced)– Refer generally
Upper Extremity – Hand
• Mallet Finger
– Cannot Actively Extend DIP joint
– Distal Phalanx held in flexion
– Rupture of Ext digitorum tendon(s)
– Stax splint (DIP joint only) x 6-8 wkDO NOT REMOVE AT ALL
If splint is removed, the clock restarts
High level of noncompliance
Upper Extremity – Hand
• Jersey Finger– Contact sport injury, grabs a jersey– Rupture of FDP – Cannot actively flex @DIP especially
against resistance– REFER to hand surgeon– Surgical reattachment
Trigger Finger
• Stenosing Flexor Tenosynovitis– Tendon thickening at the A1 pully– Fingers can get locked in flexion– Often patients wake up with this– Can be due to specific work/activities– Acute: Trial of splinting, activity
modification & NSAID’s– Persistent: Corticosteroid injection
can provide long term relief
Upper Extremity – Hand
• Boxer’s Fracture – 5th MC neck– EtOH often involved– Male, punching a wall– XR images– Tx: No displacement & no/slight
angulation = Ulnar gutter splint 3-4 wk– Tx: 30°+ volar angulation or
displacement = surgical pinning
Hand Arthritis
Finger Arthritis Characteristics1. Rheumatoid - MCP, PIP
– Erosions, periarticular osteoporosis
2. Psoriatic – DIP– Erosions, dactylitis = sausage digits (pencil
in cup)
3. Osteoarthritis – DIP, PIP– Joint space narrowing, productive changes,
osteophytes, subchondral sclerosis/cysts
Chest/Ribs
• Commotio cordis– MOI - Blunt trauma to chest wall– Baseball – boys & teens– Triggers VT or Vfib– High fatality rate– Early defibrillation can be life saving
Adolescent Idiopathic Scoliosis
• Definition: Cobb angle> 10°
• Standing scoliosis XR to diagnose
• Females more likely to need treatment
• Mild < 20°
– PE w/ height & Tanner staging q3-6mo
– Monitor for progression –serial XR
• Cobb >20°
– Refer generally unless postmenarchalor low growth potential
Lumbar spine – LBP Red Flags
• Night pain – wakes out of sleep• Pain out of proportion to exam• Cancer history• Neurologic deficit• Systemic/B symptoms
– Fever, weight loss, night sweats• Age > 50, Age < 18• Osteoporosis history (compression fracture)
Low Back Pain
• Lumbar Stenosis– Older age– Worse with Extension
• Lumbar Disc Herniation– Younger, middle age– Acute onset, sometimes next am– +/- Popping sound– Pain worse w/ Flexion, sitting
Lumbar spine
• Spondylolysis– Stork test– XR – scotty dog
• Spondylolisthesis– Shifting can occur with bilateral –lysis
• If significant can require surgery– Degenerative type (DDD)
Lumbar Spine – Spondy…• SpondyloLYSIS – fracture of pars interarticularis region
– Usually occur during adolescent/teenage years– May be Unilateral or Bilateral – 85% at L5– Many asymptomatic– Some are stress related or sport specific – repetitive/extreme
posterior loading or back bending• Runners, gymnasts
• Diagnosis – history, exam (stork test), Imaging – XR = OBLIQUES to see…
• “Collar on Scotty dog” – Xray sign• MRI or CT scan will be definitive if Xray unclear
Lumbar Spine – Spondylolysis
Low Back Pain Acute & Subacute
• Clinical guideline for Acute, Subacute & chronic LBP from ACP 2017
• Acute (<4wks) & Subacute (4-12wks) Treatment Recommendations– Nonpharmacologic
• Heat• Massage• Acupuncture• Spinal manipulation – Osteopathic or Chiropractic
Low Back Pain Acute & Subacute
• If Pharmacologic treatment is desired– NSAIDS– SMR – skeletal muscle relaxers
• No Bed Rest!
Chronic LBP - Treatment
• Chronic LBP is defined as > 3 months– Exercise– Multidisciplinary rehabilitation– Acupuncture– Mindfulness-based stress reduction– Yoga, tai chi, CBT, progressive relaxation,
biofeedback, etc– Spinal manipulation
Chronic LBP - Treatment
• If inadequate response to all of the above…– NSAIDS = 1st line– Duloxetine (Cymbalta) = 2nd line– Tramadol = 2nd line
• Clinicians should only consider opioids as an option for those who have failed all of the above AND if the potential benefits > risks after a realistic review of the potential harms & benefits
– Ann Intern Med 2017;166:514-530
Cauda Equina Syndrome
• Massive posterior disc herniation may cause critical compression on all descending nerve roots
• Urinary Retention = #1 MC sign• Loss of Motor control of Lower Extremities• Loss of Bowel +/- bladder control• Surgical emergency • MRI diagnosis
Lower Extremity - Pelvis• Iliac Crest Apophysitis
– One of the last growth plates to close– Mid to late teens– Female runners
• Avulsion Fractures• Ischial tuberosity - hamstrings• ASIS - Sartorius• AIIS – Rectus femoris• Pubic bone – adductors, gracilis
Posterior Hip PainPATHOLOGY
• Gluteus Medius – Pain/strain from overuse & weakness– Muscle/tendon tear - Trendelenburg
• Piriformis Syndrome– 11% of population will have all or a portion of the
sciatic nerve running through the Piriformis muscle
– Piriformis spasm can mimic Radicular symptoms but may be more diffuse/generalized, not as dermatomal
– OMT can help!
Lower Extremity
Red Flags• Night pain – wakes out of sleep
• Pain out of proportion to exam
• Cancer history
• Systemic/B symptoms
– Fever, weight loss, night sweats
• Unable to Bear Weight
• Long-term or multiple courses of oral steroids
• Buckling or Locking
HipPediatrics
• Transient Synovitis– Acute onset, holds hip in FABER
– Fever +/-, Labs – WNL (CBC, ESR,CRP)
– Tx: NSAIDS
• Osteonecrosis of femoral head– Insidious onset
– Legg-Calve-Perthes disease = idiopathic, ages 3-12
– Sickle Cell Disease
– Refer
HipPediatrics
• SCFE = slipped capital femoral epiphysis– Obese, Pre-pubertal usually 11-14– MC insidious onset limp & pain w/ weight
bearing or exercise, occas acute– Sx: Hip, thigh or knee pain, limb held in ER– PE: PROM limited & painful– Dx: X-ray– Tx: NWB on crutches until seen by Ortho
• Surgical pinning
Hip Pain
• REMEMBER HIP PAIN can present
as Knee pain!
• Hip –
– Femoroacetabular (CAM)
impingement
• Insidious onset w/ active patients,
• Pain w/ pivot
• PROM - pain w/ FADIR
Hip Pain• Avascular necrosis = osteonecrosis
– Insidious onset, weight bearing pain– h/o previous trauma, oral steroids,
EtOH, HIV, Connective tissue disease, Caisson’s (the bends)
– Exam: pain w/ all PROM• Osteoarthritis
– Older age– Exam: pain w/ FABER, PROM flexion
>90, IR
Knee Pain - PedsNon-traumatic
Osgood Schlatter’s =Tibial tubercle apophysitis
• Boys 12-15, Girls 8-12, growth spurt• May accompany patellar tendonopathy
• Dx: Clinical - exquisite TTP @ Tib tub, Xraysshow fragmentation, lifting off at Tib Tubercle
• Tx: Relative rest, avoid exacerbating activities, ice, stretch & strengthen quads/hamstrings
• Athletes will grow out of this
Knee Pain - PedsNon-traumatic
Sinding –Larsen-Johansson Syndrome –Inferior patella pole apophysitis
• Running & Jumping sports
• Recent Growth Spurt, Age 10-14
• Dx: TTP inf patella pole, XRay may show widening/fragmentation of growth plate and rule out other conditions
• Tx: Avoid offending activities, physical therapy, ice, stretch & strengthen hamstrings & quads
Knee PainNon-traumatic
• Patellofemoral syndrome– Anterior Knee pain, Running– Lateral patellar tracking – Weak VMO, hip abductors– Tight ITBand, ↑ Q angle– Tx: relative rest, PT
• Osteoarthritis– Tx: Active Exercise & stretching, PT
Posterior Knee Pain
PATHOLOGY• Meniscus – posterior horn injury• Popliteal Cyst = Baker’s cyst =
semimembranosus bursitis (symptom of an intraarticular process)
• Popliteal Artery aneurysm– Pulsatile mass in popliteal fossa
Knee Bursitis• Bursitis
• Pes Anserine – more likely in overweight ♀
• Prepatellar – Housemaid’s• Usually chronic• high level of infection after drainage• If acute drain if required for
diagnosis/treatment• Many other bursa in the knee
Knee - Meniscus Injury
• Meniscus Injury– MOI - Plant & twist common– Dx: Thessaly Test
• stand, flex 20° & twistMcMurray’s
– Tx: Conservative - RICE, PT– Surgical – if significant locking or
buckling, if MRI reveals bucket handle tear, if fails conservative care 2-3 mo
Knee ACL Injury
• ACL tear – most nontraumatic– Often hear/feel a pop upon landing
from a jump
– Early effusion common may be bloody
Dx: Lachman = best test, Ant drawer
Tx: Typically surgical for young & active
Less active, > 30 yo usually conservative
Knee ACL Injury
• ACL tear – Usually associated with concomitant
injuries– “Unhappy Triad”
• ACL tear• Medial meniscus injury• MCL injury
Knee Effusion
• Aspiration – indications– Diagnosis
• Septic knee – if you think this – patient should be in the Emergency room
• Gout or Pseudogout• Bloody effusion – suggests ACL tear or other
acute intraarticular derangement/fracture• Lyme – if Lyme arthritis is present, blood test
would be universally positive
Knee Aspiration• Joint fluid characteristics
– Crystals• Gout - monosodium urate crystals
– Needle shaped, negative Birefringent• Pseudogout – calcium pyrophosphate
disease– Rhomboid/polygon, positive birefringent– Associated with Chondrocalcinosis (knee
usually)
MTSS = Medial tibial stress syndrome
• Aka “shin splints”– Usually young, untrained runners– Too much mileage too fast– Associated w/ Arch Pronation– Posterior tibialis tendon traction from
pronation pulls on medial tibia– If Bone repair lags behind breakdown,
this can progress to Stress Fracture
Tibia Stress Fracture
• Tibial Stress Fracture– Runner w/ increased mileage– Exam: single leg hop, tuning fork,
edema– Dx: X-ray initially may be negative
(repeat 3 wk)– Tx: Distal fractures = Walking boot – Proximial tibia or anterior “dreaded
black line” = NWB ortho referral
Ankle SprainsInversion Injury
• ATFL – MC sprained• CFL – next likely to be injured• PTFL - last
Eversion Injury • Deltoid ligament
Dorsiflexion/Eversion Injury • High ankle/syndesmotic sprain• Tibiofibular ligaments
Ottowa Ankle rules• Ankle XR needed
– Pain in malleolar zone AND• Unable to take 4 steps immed & in ER/office• +TTP post edge or Tip of malleolus
• Foot XR needed– Pain in midfoot zone AND
• Unable to take 4 steps immed & in ER/office• +TTP base of 5th MT or Navicular
Achilles• Achilles Tendinopathy
– Chronic– Tx: Eccentric strengthening of Gastroc
& soleus• Achilles Tear
– Acute – refer for surgical opinion immediately
– Chronic – management varies
Plantar Fasciitis• Plantar fasciitis
– MCC of heel pain in adults– Pain at medial/plantar origin on calcaneus– RF: ↑weight, long standing, poor footwear– Tx: Eccentric calf stretches similar to
Achilles tx, arch supports, +/- NSAID’s, night splint, injection
Lower Extremity – Sever’s• Calcaneal Apophysitis = Sever’s disease
– Age 9-13– Growth plate inflammation from overuse, Achilles traction– Tx: PT, stretch, relative rest, (No US)
Lower Extremity – Fractures• Jones Fracture – acute fx of proximal
diaphysis of 5th Metatarsal– Active pts: Surgical referral– Inactive: NWB in cast 6 wk & repeat XR for
healing• Phalanx Fractures
– 2-5 Stiff-soled shoe & Buddy taping – 1st – May need surgical pinning
• Refer Displaced or > 25% of joint involvement
Medical Conditions
• Gout – Acutely painful, warm, swollen joint– Usually 1st toe or knee– Dx: Joint fluid aspiration,
• Labs: +/- uric acid ↑ , CBC - WNL– Treatment options
• NSAID’s, indomethacin (avoid in CKD)• Colchicine (Colcrys) (avoid in CKD)• Prednisone
Medical Conditions
• Polymyalgia Rheumatica– Pain & stiffness bilateral Shoulders, arms,
hips, other joints– Inflammatory condition– ESR elevated– Tx: Prednisone 15 mg daily (10-20), slow
taper
Medical Conditions
• Ankylosing spondylitis– Insidious onset non-traumatic LBP– Inflammatory condition– Pain improves with exercise & activity– Morning stiffness– Pain worse at night
Diagnosis - Labs
• Blood work – Lyme disease– Rheumatologic workup
• CBC, CMP, ESR, CRP, ANA, RF– Gout – uric acid– STD’s
Preparticipation PE• Do about 6 weeks prior to sport• AHA 14 point screening guidelines should be
used• Universal screening with a 12 lead ECG not
recommended• Athletes with SBP<160 & DBP <100 should
not be restricted from sport• No screening blood & urine tests
Mirabelli, MH, Devine, MJ. The Preparticipation Sports Evaluation. Am Fam Physician. 2015 Sep 1;92(5):371-376.
Preparticipation PE
• Most common cause of sudden death in younger athletes in this country (<35yo) is HCM = hypertrophic cardiomyopathy– Murmur - harsh crescendo-decrescendo systolic
@ LSB & apex increases with Valsalva or standing from squat
• MCC of sudden death in older athletes (>35yo) is Coronary artery disease
. Pelliccia,A, Link,M. Athletes: Overview of sudden cardiac death risk and sport participation. Post TW,ed. UpToDate .Waltham, MA.
(Accessed on February 14, 2019)
.
Acute Tendon Tears
These require prompt referral < 1 wk
• Achilles• Patella• Distal Biceps
.